Form for Program Directors to verify key information for selected centers

APPENDIX 10

FORM FOR PROGRAM DIRECTORS TO VERIFY SELECTED CENTERS’ INFORMATION

INSTRUCTIONS: This form is being used to verify information about your program and its centers for the Migrant and Seasonal Head Start (MSHS) Study. Instructions are provided below separately for each section. When finished, please return this form to the Westat study team by emailing XXX@XXX.com. If you have questions about this form, please call us toll-free at 1-888-XXX-XXXX.

Section 1: First, we want to review the MSHS program information below for accuracy.

Please select one of the following statements about the program information listed below:

___ This information is correct

___ This information is incorrect/incomplete

(If incorrect or incomplete, please update information in yellow section below)

	Please review:	Corrected Information:
Program Name
Grant Number
Program Number
Program Type
Program Address
Program City
Program State
Program Zip
Program Main Phone Number

Section 2: Next, we want to confirm information for accuracy for MSHS centers affiliated with your program.

Center #1: Is all of the center information below correct and complete? Please select one of the following statements: ___ This information is correct ___ This information is incorrect/incomplete (If incorrect or incomplete, please update information in yellow section below)
	Please review:	Corrected Information:
Center Name
ID
Center Address
Center City
Center State
Center Zip Code
Center Primary Contact Name:
Center Main Phone Number
Center #2: Is all of the center information below correct and complete? Please select one of the following statements: ___ This information is correct ___ This information is incorrect/incomplete (If incorrect or incomplete, please update information in yellow section below)
	Please review:	Corrected Information:
Center Name
ID
Center Address
Center City
Center State
Center Zip Code
Center Primary Contact Name:
Center Main Phone Number
Center #3: Is all of the center information below correct and complete? Please select one of the following statements: ___ This information is correct ___ This information is incorrect/incomplete (If incorrect or incomplete, please update information in yellow section below)
	Please review:	Corrected Information:
Center Name
ID
Center Address
Center City
Center State
Center Zip Code
Center Primary Contact Name:
Center Main Phone Number

Section 3: Finally, we'd like to ask you some information about the numbers of classrooms and children, start and end dates, and peak attendance periods at each of the MSHS centers affiliated with your program.

Next to each MSHS center listed below, please complete the information in the spaces provided in response to the questions at the top of each column, based on the prior year's information. When reporting, include ONLY those centers, classes and children funded through Federal ACF MSHS funds. If an MSHS center has closed, write the word CLOSED in the yellow space next to the Center Name. To determine children's ages, please use the cut-offs used by your local school district (the same you used when reporting PIR data). Your best estimates are sufficient.

MSHS Center Number & Name	a. What was the maximum # of classrooms with children enrolled in this MSHS center during 2015?	b. What was the maximum # of infants (birth to 2 years) enrolled at any given time in this MSHS center during 2015?	c. What was the maximum # of toddlers (2 to 3 years of age) enrolled at any given time in this MSHS center during 2015?	d. What was the maximum # of 3-year olds enrolled at any given time in this MSHS center during 2015?	e. What was the maximum # of 4-year olds or older enrolled at any given time in this center MSHS during 2015?	f. What was the opening date for MSHS classes in 2015?	g. What was the closing date for MSHS classes in 2015?	h. What was the estimated peak attendance period start date in 2015?	i. What was the estimated peak attendance period end date in 2015?	Comments:
# 1.
# 2.
# 3.

Paperwork Reduction Act Statement: This collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is [0970-XXXX ] which expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 30 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Abt Associates, 55 Wheeler Street, Cambridge MA 02138 Attention: Linda Caswell.